Tobacco Cessation for Primary Care Providers

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Tobacco Cessation for Primary Care Providers
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Clinical Practice Guideline for Tobacco Use
Dependency

• Tobacco Use Statistics
• Strategies for Implementation
• Health Promotion Behavioral Program
• Pharmacology

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Tobacco Use Statistics

• 70 of smokers now want to quit
• 46 of smokers try to quit each year
• Nicotine is an addictive drug, more addictive
  than heroine and cocaine
• Tobacco dependency is a chronic condition the
  warrants repeated treatment
• The average person takes 5 serious attempts to
  quit before successful

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Cessation Statistics

• 7 of smokers are able to quit on their own.
• Can increase that from 15-30 by using
  dependency counseling and pharmacotherapies.
• Even brief treatments such as physicians advice
  to quit can increase abstinence significantly.
• Smokers cite physicians advice to quit as an
  important motivator

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Role of Clinical Intervention

• 70 of smokers visit a health care setting each
  year
• Brief tobacco dependency treatment is effective
• Strong dose-response relationship between
  intensity of counseling and effectiveness
• Counseling most effective
• practical
• social support as part of treatment
• social support arranged outside of treatment

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Strategies for Implementation

• Intervention Steps- 5 As
• 1. Ask-about tobacco use
• 2. Advise-to quit with a personal message
• 3. Assess-stage of readiness
• 4. Assist-with both counseling and
  pharmacotherapy
• 5. Arrange-for follow-up or referral

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Ask

• Non-judgmental
• Open ended question, Tell me about your smoking
  habit.
• I see that you use chewing tobacco, how long
  have you been using it?
• Do you use any form of tobacco?
• Goal Ask every patient if he uses tobacco and
  document in PHCA

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Advise-tailor the message

• Give information about the effects of smoking on
  their body
• Stress the benefits for them of quitting
• Give a clear recommendation to quit
• The 4 Rs
• Goal A clear strong personalized message to urge
  every smoker to quit.

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The 4 Rs

• Relevance Information relevant to patients
  disease status, family life or social situation
  has the greatest impact.
• This is a very individualized message you give
  them based on your assessment of their situation.
  
• What does smoking do for you?

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The 4 Rs

• Risks Ask the person to identify the potential
  negative consequences of smoking.
• It has to be the patient who identifies their
  negative consequences of smoking, you cant do it
  for them.
• How do you think smoking will effect your life?

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The 4 Rs

• Rewards Ask the person to identify the potential
  benefits of quitting. Highlight and elaborate the
  most relevant benefits.
• How do you think you will feel after you quit
  and what will the benefits be for you?

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The 4 Rs

• Repetition Repeat the message at each visit. The
  message is that they need to quit and we are
  interested in helping them.
• Have you made any progress toward quitting?

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Assess-Stages of Change

• If we give you some help would you be willing to
  give it a try to quit smoking?
• Goal to move forward along the continuum

How we Want to change
non-smoker smoker
How we Actually change
non-smoker smoker
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Stage 1 Precontemplation

• Not even aware that a change is needed
• May be resistive to change
• The cost to change is too high

Assist Arrange Discuss benefits to the patient.
Personalize the smoking cessation message. Avoid
arguments Goal Move patient toward considering
quitting-Contemplative
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Stage 2 Contemplative

• Realize a change is needed
• Intend to change
• Not sure how to start
• Ambivalent

Assist Arrange Affirm their desire to change.
Provide HP referral information, Smart Move
brochure, encourage making a plan. Goal Move
patient toward a quit date, preparation
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Stage 3 Preparation

• Are taking some action
• Have a plan and are starting to make changes

Assist Arrange Affirm, support, encourage,
reinforce reasons for quitting Provide HP
referral information and Smart Move
brochure Goal Move patient to stop
smoking-action
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Stage 4 Action

• Taking action on a regular basis
• Developing a regular habit
• Picking yourself up after each setback

Assist Arrange Assist in resolving any residual
problems Goal Reinforce the decision, review the
benefits, reinforce reasons for quitting, prevent
relapse.
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Stage 5 Maintenance

• Taking action on a regular basis
• Behavior change has lasted more than 6 months
• Change is a way of life

Assist Arrange Affirm, congratulate, reinforce
reasons for quitting Goal Prevent relapse and
affirm stress management techniques
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Case Study-Donna

• Donna is a 56-year-old, 2 packs a day smoker. She
  has smoked for 40 years. She has never really
  tried to quit for more than a day. She knows it
  is bad for her but she worries she cant quit
  because she has always smoked.

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John

• John is 26 and has been using chewing tobacco
  since he was in high school. He believes it is
  much safer than cigarettes and not near as bad as
  other things he sees people doing. He says it
  helps him through his boring day and doesnt
  bother anyone else since there is no smoke
  involved.

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Bill

• Bill is 35 and has been smoking since he was 12.
  He has tried 4 times to stop smoking, one time
  lasting 2 years. He knows it is not good for you
  but he cant stand the way he feels trying to
  quit. He says he tried the patches the last time
  he attempted to quit but they made him sick.

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Tina

• Tina has not had a cigarette for just over 1
  month now. She tried several times before this to
  quit, but was only able to go for 2 weeks. Her
  husband is being deployed next month and she will
  be left at home with three small children. She
  worries if she can do without smoking when he
  leaves.

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Health Promotion Behavioral Program

• Understanding the nicotine habit and addiction
• Establishing personal reason for quitting
• Setting a quit date
• Making a plan for quitting
• Recovery symptoms (withdrawal)
• Stress Management and support
• Relapse prevention

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Smoking Cessation Program

• American Lung Association-Freedom From Smoking
  classes
• One-to-one counseling
• Support adjuncts-pharmacotherapy, self-study book
  and tape, substitute cigarettes, mint snuff,
  relaxation tapes, videos, brochures for all
  stages, stress balls, water bottles

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Pharmacotherapy Agents
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How to Choose Pharmacotherapy

• Zyban Highly addicted/High user- over a pack a
  day
• long smoking history
• tried other methods of quitting
• increased cravings
• irritability with quitting
• concerned about weight gain
• adhesive allergies

Space in user-
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How to Choose Pharmacotherapy

• Nicotine Replacement Patch
• No experience with cessation attempts
• short smoking history
• Already on anti-depressant medicine
• Patient declining Zyban (fear of medication)

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How to Choose Pharmacotherapy

• Combination of Patch Zyban
• Increased cravings on patch
• Can add Zyban to patch or patch to Zyban
• Combination may increase abstinence rate to 35
• Published Abstinence rate
• Zyban alone-30
• Patch alone-16

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How to Choose Pharmacotherapy

• Side effects
• Medication discontinuation rate may be up to 35-
  40 with all medications secondary to side
  effects

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Key Points

• Everyone needs to be asked
• Tobacco cessation is a change process and success
  is measured by the forward moves through the
  stages of change
• Pharmacotherapy combined with a behavioral
  program is a cornerstone
• Relapse prevention counseling is necessary
• Providers can make a significant difference in
  patients motivation and success